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Take a long time as well. But the most important thing is tailoring the examination to the patient. So, like I said, a lot of the times when a patient comes into A and D or if you're on the ward, certain things that need to be tested is obviously upper limb, lower limb, if there is a query of stroke or if there's any other conditions which we will go through throughout, we want to basically not complete the whole thing because this can take maybe half an hour or 45 minutes if you're going through it from A to Z. But generally speaking, the neurological examination consists of a couple of main things that I've listed here. So first being your mental status, this is one of the most important things to check for first and we'll discuss why the next most important thing is checking for skull spine and meninges. This could basically give us a quick indicator as to what is going on with the patient. One of the most important things that you need to basically go through is your cranial nerves. So I've broken it down and we will go through each one in detail as well to discuss why cranial nerves are important, testing it. What, what are we testing for with each cranial nerve and what the significance of it is then more importantly, which is very tailored to your neurological examination is your both your motor and sensory function. This will give us an indication about any focal lesions that are present there. And then we'll shortly discuss about coordination gait and station. If we can go on to the next slide, I will discuss about mental status in a bit more detail, right? So when we're discussing, discussing mental status, we wanna know any if there's any underlying condition. So whenever you see a patient, whether it's for your ay, whether it's for seeing a patient on the wards, the most important thing is taking an important history and trying to find out their underlying conditions, whether that's the past medical history, whether it's something that they are presenting with. Currently, sometimes you can even ask for um a um a history from any, any let's say family who are with them. So let's talk about dementia first. Now, dementia, obviously, there's, it's a broad, broad topic, should I say? So, dementia, we need to talk about which types of dementia can be causing it, whether it's vascular dementia, Lewy body, dementia, all of them have different presentations, but they all alter the mental status. Next one that's important and you will come across it a lot is delirium Now, delirium can be caused by many factors. First of all, elderly patients generally can present with delirium if they are constipated. If they are on lots of medication, if they've had a change in medication, electrolyte, imbalances, all of these affect their mental status. Depression is another important one. So this is very significant to find out if it's an acute case or if it's a chronic case, certain people who present acutely with depression will also have signs of delirium. And the last one is if they are in a comatose patient, that will obviously be seen if you see the patient directly and you will see that on the next phase when we talk about the Glasgow coma scale. Now, the Glasgow coma scale is very important and it's one of the most important things you will examine in a patient, which is part of your mental status. Now, this can be broken down into three main categories. First one being your motor responses, your verbal responses, and your eye movements. Now this is if you remember, move M ve and if you remember the numbers 654, that's the best way to check the responses for them. Um I'm not going to go through it. There's a little picture on the side. I don't know if you can see it clearly or not. But again, if you have any questions with regards to any of these, you can either message it and I can get back to you now or we can do it at the end, whatever is easier for you. But Glasgow Kerma scale is very important because this gives you an indicator on how well the patient is doing. Are they deteriorating? Fast, slow? Has anything changed upon admission or not? The next things we're going to talk about is focal cortical functions. Now, these are very important because it assesses three main things, aphasia, apraxia and agnosia, aphasia is very important because it tells you about two main things, whether it's expressive aphasia or receptive. Now, in the case of patients having expressive aphasia, they are able to. So this will be affected in the dominant hemisphere of the patient in the BRCA area. And this will basically allow the patient to fluently speak, but without actually understanding anything and receptively is fully able to understand anything but they are not fluent in their speech. The next one we're going to talk about or the next two we're going to talk about is agnosia and apraxia. Now, these are defects in recognizing complex sensory and motor simulus. We'll get to this in more detail when we start with the examination for it. And the last thing that you need to basically checking is the cognition of the patient. So this can be done in a variety of ways. Orientation. Generally speaking, you will on an admission or if you are seeing the patient, you will ask them. First of all, do they know where they are. Do they know what time of day is? Is it morning, night or evening? Do they know the date specifically? And then for memory, what we'll say is you'll tell them to remember either a number, for example. So you'll say, remember the number 42. And at the end of the mental state, at the end of the mental examination, you will ask them again. Do you remember what I asked you or you whisper something in their ear and ask them to repeat that back to you with intellect, abstraction and judgment. This is very important in terms of judgment. You can ask them a basic or a simple question as if you were crossing the road and if a car was coming at, let's say a certain speed, 60 miles an hour and it's 5 m away for you. Are you going to cross the road or not? That will then give us an indication on their judgment. Would they find it completely normal to cross the road? Would they give you a detailed idea as to why you shouldn't cross the road? That will give us an indication in terms of intellect. One of the most common things that we use in clinical practice is tell them to, let's say, count down by seven from 100 so 100 minus seven minus seven and do that for the next five sequences. Uh Next one, can we go on to skull spine? And meninges. Now, skull spine and meninges. This is another important aspect of your neurological examination. Again, this can be done almost immediately. So as you're walking into the ward or as you're going to see the patient, you will basically know this straight away. So first thing you want to be looking at is the skull. Is there any signs of trauma or surgery based? Now, if there is surgery based, uh, first of all, you can see on their notes on admission, you can see from prior surgeries that they've had trauma related if they've brought into the emergency department. The most important things, are there any signs of any hematomas, bleeding or bruising, any lacerations that are present there? And the next most important thing you want to be looking at is the midface. Now, the mid face is the most important because sometimes, let's say, for example, very frequently in car accidents, do you have accidents which actually affect the Le Fort area? So these are broken down into three le fort 12 and three, if any of them are actually broken. So any of the bones within the mid face are broken. Patient can present with CSF otorrhea. So CSF coming through their nose, which is almost like a bright yellowy coloration that's coming out or you can get rhinorrhea as well. These are all related to the CSF this is an immediate admission and obviously you need to assess the function straight away if a patient presents with any of these defects on their skull, most probably their Glasgow coma scale is not going to be 15. And that's one of the first things that should be assessed. The next most important thing that you want to be looking at is the spine. So checking for any deviations within the spine itself, scoliosis, sometimes if the patient comes in and they present, obviously, they are just sitting on the bed, they are going to be struggling to move. So you can ask them prior to the incident or prior to the accident, how was their range of movement? So for example, other factors that you can consider in the differential diagnosis is you could consider thinking about. Is there any ankylosing spondylitis that they have present? There? Is there any stenosis that is present there? Have they had any previous surgeries to the spine? Have they had any lumbar fusion treatments going on? And the next most important thing that you want to be discussing is the sciatic nerve test. So I don't know if many of you have nerve tests before, but it's a very quick test that you can perform for the patient. You basically get the patient to sit on either the side of the bed or you can if they are not mobile and they're just lying in bed, you will first of all lift both legs up together, making sure they are straight. Sometimes if the sciatic nerve test is positive. They will complain about a pain which is either radiating from the hip down to the knee or it's presenting all the way down and it's going towards the ankles as well. And then you would basically do it with one leg and the second leg. Generally speaking, when you do the sciatic nerve test, you will hardly ever find it where it's bilaterally positive. So one leg will be generally worse than the other. Sometimes they will get a bit of muscular pain. But you want to see if they present with any shooting pain. The next thing that you want to be discussing or having a look at is the meninges. So obviously, differentials for this, you can be thinking of meningitis, but again, this could be due to any trauma as well. So first, most important thing you want to do is see if there is any pain upon neck movement. So neck flexion. So you could either do the BRZ or the Koenig sign. Again, if they, when they are lifting this, if they, if you notice that they go into the fetal position or they are lifting their knees up towards their chest, this will suggest a sign that there is an issue with their meninges. And if indicated, a lumbar puncture may need to be done. Let's go on to the cranial nerves now, right? Cranial nerves. So let's talk about the cranial nerves. Uh Let's start off with the olfactory So traditionally, when in your ay, when you were doing it, smell would be done either through with a little box of something. So generally speaking, it would be coffee beans or something like that. Now, it's actually changed and you actually get these little scratch cards, so you scratch the little scratch card and you get the patient to smell it and let them know if they can smell it or not. Or essentially when you are taking the history. The first important thing that you want to be asking them is have they noticed any changes in their smell or not? The next one we will talk about is the optic nerve. Now, the optic nerve is very important because first of all, again, history is always important when taking cranial nerves. So you want to find out if they have had any issues with their visual acuity or visual fields in the past, they have any underlying issues. For example, glaucoma cataract diabetes related complications that can affect their visual acuity. But the most important thing is have they noticed any changes in their visual acuity upon admission or prior to admission? So visual acuity will be done on the Snellen chart where you will be charting. I don't know if you guys are aware of how the, how the Snellen chart works. But if you, if I can't get an image up at the moment, but maybe at the end, we can go through it and get the smelling chart up, but it's a chart and you get the patient to stand at a certain distance away and you get them to read the number from the top to bottom. First of all, you'll start off with closing one eye. So basically covering the right eye and reading with the left eye and you do the opposite by covering the left eye and having a read of the right eye. And then at the end, you would get them to do it with both eyes. Visual field is quite simple. You will hold a pen up in front of the patient. You would make sure that they look, look straight at all times and you will basically go across all the fields. So you'll start off by going left and then from left, go back into the midline, from the midline to right and then go up and then down and then go into the, into the upper quadrants as well. So go diagonally to the left, right, etcetera. Does that make sense? Then now we'll talk about the oculomotor trochlear and abducence nerve. Now, this is basically checking for the symmetry of the pupil response to light and the swinging light test. So when you're basically doing this, you will have a look at it the pupils first of all, and you will compare the left to the right or the right to the left, then what you would do is you would put your So you would have the direct and consensual light response test. So direct is basically when you don't put your hand in front of the patient and you're moving the light or a pen torch from one eye to another and you want to see is if the eyes are actually reacting to light or not. So in certain conditions, they don't actually respond to light but they do accommodate. So a common condition that you will see is the home, the home a pupils where they respond to light, but there is no accommodation. Then the next thing you want to be doing is the swinging light test where you will move the light from one eye to another and see if there is a response or not. Now, in the case of a common condition, for example, optic neuritis, you will have a relevant a relative afferent pupillary defect. So therefore, the swinging light test will be negative. In this case. Next one we'll talk about is the trigeminal nerve. The trigeminal nerve is quite a complex nerve because it consists of the both sensory and motor functions. So in the case of the sensory function, the best way to do it is get a cotton wall and a sharp object. Ideally nothing too sharp where it's going to cause any, any bleeding or any abrasion to the skin, but something like the end of a pen or, or anything that has a tip to it. And what you would do is you would run it across. So we know the the motor branches across it and they run along the sensory branches too. So what you want to do is start off at the top of the face laterally and you just want to basically softly touch it and you want to see if the patient can feel it, make sure their eyes are closed throughout this test. So they can't see what you are doing and then also complete this with a sharp aspect as well, making sure they can feel it at any point. If they say that they cannot feel it, retest it and make sure you check both the left and right side too. In terms of the corneal reflex, you get um a little bit of a cotton wool and you literally just touch the inside of the cornea and see if they actually start to blink in terms of the motor response to it. You will ask them to do a range of movements. So first of all, opening their mouth, getting them to smile, frown, lifting their eyebrows, all of these will give us an indicator. Now, this is very important because we will discuss it at the end. But the trigeminal nerve has a, has a big uh response in finding out whether it's a upper or lower motor lesion. Next, we'll talk about is facial nerve. Again, we'll check for symmetry, get them to be doing the movements smiling, get them to blow their cheeks and also taste. So taste can be very important. Generally speaking, within the wards, they are not tested as frequently. You will ask the patient if they've had noticed any change in taste along with smell, that's very important. The next one that's important is the vestibular cochlear nerve. Now, this is where you actually check if they've got any conductive hearing loss or sensor neuronal hearing loss. Now, the best way to test this is by doing the Weber and the rine test. So check the patient's history and also ask them if they've noticed any changes in their hearing in the past couple of days or if this has been a chronic issue as well. Now, I don't know if you want me to discuss the Weber or R test or if you've done them before. But uh basically, generally speaking, when you're doing the sensor neuronal hearing test, generally speaking, when you're doing it, air should always be greater than bone. And that's the case in sensor neuronal hearing loss. And also if when you are completing the test, you will notice that it lateralizes away uh in the case of um conductive hearing loss, bone is greater than air in this case. And it basically presents to the same side as the ear, glossopharyngeal and vagus nerve. This is very easy. You get the patient to open their mouth and say, ah upon the patient saying you will basically look at the palate, making sure that they are symmetrical and the ovula is in the midline. Now, another thing that's important to remember is in certain conditions, the ovula can be deviated slightly, especially if they present with acute issues, for example, tonsillitis or any foreign bodies or any anything like that can be that can deviate the ovula in terms of the accessory nerve. The most important thing for this is checking the motor function of the two muscles that innervate. So we'll be checking for the motor function of the sternomastoid and the trapezius muscle. Now, the best way to check for the motor function of the sternomastoid is you get the patient to move their head from laterally into the midline against resistance. So you'd put your hand there and you'd get them to move it. You would assess the power on each side providing that they are both equal. The motor function for the Stenoclada Mastoid is preserved. In terms of the Trapezius muscle, you would keep your hands on top of their shoulders and you'll get them to do some shoulder shrugs. Again, first of all, you'll get them to do the right side or the left side and then get them to do it together. Again, you would assess the tone and the power on this and you would document that down saying that power is equal bilaterally or one side is weaker than the other. The last one is the hypoglossal nerve in this case, you will be basically checking for the patient to move their tongue. So you would get them to move it first up to touch the palate, then to the floor of their mouth and then to either cheeks or make sure they are touching each buccal surface from the left to right. Again, note that it should be all. If the examination is normal, note that movement is intact and it's normal on each side. If there is an issue, then you can state that uh tongue movement on the left is not, is, is not as good as the left side. And again, you can put a number to it as well to say that if the movement was only B or it didn't move deviate from the midline or not. Does that make sense? If that's all good? If you have any questions, you are more than welcome to write them down as well and then we can go through them at the end. Can we move on to upper limb? So now, upper limb, these are more specific uh aspects of um neurological examinations don't be while you're reading the slides, don't be too worried where it says C five C six. These are all the dermatomes. And again, not a lot of people remember them again. As long as you remember which tests need to be done, you can always look back at it later on and then write that down. So what's the most important things you want to be looking at when you're looking at the upper limb. So upper limb and lower limb, they are very similar in terms of the first things that you start to do. So the first thing you look for is any scarring, is there any scarring that's present there that could be due to previous surgeries or anything like that? And then you look at any muscle wasting. So again, these are always important to examine by looking at the left and the right and making a comparison between them. So, is the wasting on either one side or is it bilateral? Then upon just examining the patient, you want to be looking at if there's any involuntary movements that are occurring there. So again, this could then give us an insight of if there's any focal neurological defects that are occurring in the patient, then we'll talk about fasciculations. Now, fasciculations are spine movements that a patient can basically have. And this is generally, again, when we discuss the upper motor neuron and lower motor neuron that will play a big significance in there. And the next one we want to be looking at is tremor, whether it is resting tremor, whether it is any other type of tremor. Again, a good history will give us an indication about tremor. Again, speaking to the patient, generally speaking, tremor can present acutely, but a lot of people who have tremor would have had it chronically. So again, a good history and any underlying medication also can give us an indication as to if anything is causing tremor as well. So the first thing you want to be looking at is something called the pronator drift. Now, what you get the patient to do is stand up, close their eyes and keep their hands out in front of them. In the case of a positive pronator drift test, what you will notice is one hand will start to drop down against gravity. If that's the case, what we're looking at is the upper motor neuron primal pathology, which again we'll discuss in more detail. The next thing we want to be looking at is the tone. Now, even though I've just documented it in terms of your Aussies, when you are assessing tone for the patient, the best way to assess the tone for the patient is, let's say you're looking at the tone around the elbow joint. For example, what you want to do is put one hand above the elbow joint and one hand below the elbow joint. So one at the biceps and one at the forearm. And what you wanna do is slowly roll it in your hand almost like you've got a rolling pin in your hand and you wanna roll it left to right now. Generally speaking, when you roll it a normal tone, it should be, when you tell the patient to relax, it should be very easy to do. If in the case that you notice that there is any cogwheel rigidity, what you'll notice is resistance at a certain point. So this may take a while. So what you want to do is take your time when you are assessing tone. So don't just check it once and leave it because in the case of cogwheel rigidity, it can take up to a minute for this to assess. So if you roll it slowly clockwise and then back anti clockwise. When you are doing this at certain points, if you notice some resistance, in that case, you may consider it to be cogwheel rigidity. Another time you may want to see is if there is increased tone. So again, you can assess that by looking at the left arm and the right arm and then documenting and making the decision. Now, in the case of stroke, for example, you will generally have an increased tone. So again, when you are trying to move it, you will notice that it's a lot more difficult and you actually are putting a lot more pressure in when moving it. The next things that you want to be checking for is the power. Now, power is graded on again, 0 to 5 with five being that it's completely normal with zero being that there is no movement there at all. Now the first one you want to start off. So when you are generally assessing, always start off from the top of the upper limb and then progressively go down. So follow the dermatomes. So first of all, you want to start off with is shoulder abduction and abduction. Now, generally how that's done is again, you would get them to move their shoulder joint or their arm away from the midline and bringing it back into the midline. That will give us an indication. Again, you can state when you are doing it, check it against resistance and making sure. So you get the patients to push their arms out and then try to bring their arms back in. Again, write down and document down that whether the power was between 0 to 55 being completely normal, zero being that there is no movement there at all. And you had to make all the movement the same with elbow flexion. Now make sure that their hands are placed at a point where it is against gravity. So then you can then flex the elbow joint and extend the elbow joint at both points. Again, document down the power that is present there and the same with wrist extension. Now, when you are doing wrist extension, if they are sitting down, then you can get them to lean their wrist over their knee. For example, if they are on the side of the bed, then you can aid the patient by holding the patient's hand in your non dominant hand and using your dominant hand to basically allow for wrist extension and flexion reflexes. The most important ones that you want to be checking are your biceps and triceps. So these are your C five and your C six and C seven and C eight. Now, generally, when you are doing your uh checking for your reflexes, sometimes you may not notice that you can see a reflex. The most important thing when you are doing both your biceps and triceps, reflexes is not to notice your the movement of the hand, but rather to keep an eye on the biceps tendon. So where you're striking it, you want to see if there is any movement within the tendon itself. So a lot of the time or when you are looking at it on videos or in Aussies, it's very exaggerated where the patient will move the whole hand when you're actually doing it on wards. The most important thing that you will notice is you will see a little bit of a pulsator, a pulse type of movement on the tendon itself. The next thing you want to be checking for is the sensation. Now, the sensation again, similar like when we were checking the trigeminal nerve for sensory and motor function, you want to be starting off by with a cotton wall and a small sharp object, uh generally speaking. So I've documented or I've written down that you said you should start off at the chest. Now, that's not always the case, but the reason why I mention that the chest is generally the best place is if in the case, the patient has had a stroke or they are um paralyzed. So they are tetraplegic quadriplegic. In the case, generally speaking, the place that is generally normal is the chest. So the midline of the chest or on either side of the chest. So you start off by with a cotton wall and you just have a feel of the uh just rub it, make sure the patient's eyes are closed and say, can they feel that sensation? Then what you do is you follow the dermatomes of the upper limb. So start off with the hands first. So use the cotton wool and rub it on your, on the little finger, then go to the middle finger, uh continue progressively up until you reach the point of the chest. Now, at any point, now, a lot of people ask, well, what's the point in, in checking for sensations or or not? Now, this is very important because for certain people, when they're checking sensations, they may have sensation in their hands, but they may not have it at the upper limb. This will give us an indication of where the lesion is within the brain or the brain stem itself. So it's very important to document this down. The next thing we're gonna talk about is coordination. Now, coordination is, is a very important thing, but it's a very quick test to do. So. The best thing you want to be doing is get the patient to basically put their thumb and the other fingers. So keep their thumb in place and make sure they are touching each finger to their thumb and making sure they can do that. And then you would ask them to try to increase in their speed and making sure that they are touching it correctly. Make sure you are doing it on both sides. So first check the right hand, then followed by the left hand, making sure they are doing that correctly. Then what you get them to do is with each finger on the right hand and the left hand get them to touch their nose. But when they're touching their nose, don't get them to do the first, the first finger, second finger and third finger first get them to touch their finger with the first finger on their nose, bring their back, bring their hand back down to the normal position and then do the second one because this will give us an indication of if there is any issues with their coordination as well. And the last one is make sure that their finger get their, their finger to touch your finger again, assess them with all the fingers and making sure they are correct. Generally speaking, if you do the first, the first couple and you notice that it's completely fine, you can state that coordination is intact and there's no issues with it. Let's go to the lower limb. Now again, lower limb is similar. The first things you want to be checking is for scarring, wasting any involuntary movements for circulations and tremors. Let's talk about tone again is the same thing. Let's talk about uh power again when you're assessing the tone. Sorry, let me mention about the tone when you're assessing the tone for the patient. In this case, what you want to be checking the tone for is first start off within the knee joint. So again, keep one hand above the knee, one hand below the knee and slowly have a rolling motion. Again to assess the tone. Again, do both sides and make sure you check if there is any issues with it and document that down too in terms of power. Now, the first one that I mentioned hip flexion in elderly patients, this can be significantly difficult. Uh generally speaking, they can have underlying osteoarthritis or they could have had previous surgery. So it's very important to check the patient history before trying to check for hip extension and flexion. First, you don't want to put them in more pain and agony as as they already are in, then you want to be checking their knee flexion and extension, making sure that's all documented. Now, knee flexion, flexion and extension. This is important to remember because I don't know if you remember, but I did mention about doing the sciatic nerve test. Now the sciatic nerve test when you're doing it, it has, it follows the same dermat L3 L4, uh and uh S one as well. So you want to be careful that when you are lifting this, that you're not actually doing the sciatic nerve test. So actually bend the knee at the hip and then do the knee, uh, knee flexion and extension for the patient. In terms of ankle, dorsiflexion and plantar flexion. Again, hold the patient's uh leg in your hand at the ankle joint and slowly dorsiflex, uh or plantar flex the ankle. Then we wanna be checking for their reflexes, knee flexion again, keep your, when you're doing this, make sure the knee is hanging off the edge of the bed or if they are lying in bed and they're not mobile, then slowly flex the knee, uh flex the hip and then hold the patient's uh knee. Uh hold it, hold the, hold your hand under the knee with your non dominant hand and striking the knee to check for a knee reflex. Now, again, this one is a lot easier than the biceps or the triceps reflex and you should get quite an exaggerated response with it. And that's the same with the ankle as well. Again, with the sensation, what you generally want to do is again, start off with the chest and when you start off at the chest, say, can they feel this and then start off laterally? So always start off with the little toe and then go to your big toe. So S one and L5 respectively and then slowly go up the uh go up the leg and see if they've noticed any changes again, at any point. If they say that they cannot feel it, repeat it again and again, if that comes back positive, then document down saying that along this dermatome, you've noticed that their sensation has been affected. Now let's go on to upper motor neuron and lower motor neuron. All right. 01 2nd. Let me just respond. II will respond to these questions at the end. Now, let's talk about upper motor neuron lesions and lower motor neuron lesions. Now, these are very, very important because this gives us an indication as to where along the brain, the brain stem or even the spinal cord. But if there is any lesions that are present there. So in the case of an upper motor neuron lesion, generally speaking, the type of paralysis that you will get is a spastic paralysis. Now, what what, what, what does spastic paralysis generally mean? In terms of a spastic paralysis, the movement will be a lot more. And also another thing that you will notice with spasticity, you will also get hyperreflexia. So when you are testing the uh reflexes of the patient, you will get a lot more exaggerated reflexes. The best one that you will generally see is when you are checking at the plantar reflex or you will notice even some uh signs of uh fast movements that are going to be present there or twitching. Another thing that like I mentioned in the case of upper upper motor neuron lesion. So the most common case is that you will see it is in stroke. For example, you will notice hypertonia. So generally speaking, the tone will be a lot more difficult when you are moving it, you will almost notice resistance. But the most important thing to differentiate between them is checking between coal rigidity and also noticing whether it is just a general increased tone. In the case of coal rigidity, you will notice resistance upon movement only at certain points. Whereas in generally, in terms of when you have a stroke and you have increased tone, you have a hypertonia throughout the movement. So you will find it quite difficult to move at all times. In the case of upper motor neuron lesions, you will not notice any fasciculations present at all, but you will have a positive babinski sign. So in the case, when you are testing it, when you are going from the heel laterally all the way to the ball, you will notice the flaring of their feet. This is a characteristic and very common sign that you will notice in upper motor neuron lesions. Um in terms of voluntary movements that you generally see it, it's very difficult to actually notice this way where it says decrease in speed. Because generally speaking, when you are checking for movement and speed, it's hard to differentiate. But the best way to check for speed is actually compare it between the other limb as well. So if you are checking the left limb and you think that the lesion is present on the left side, check it compared to the right side and document the difference between speed. That will give you the best idea in the case of lower motor neuron lesions. Um again, this is just imagine it being completely the opposite to it. So in this case, you are going to have a flaccid paralysis. So again, you're going to have decreased when you are basically making movements or you are generally trying to tell the patient to move their hand against gravity, you will notice that you will be doing all the movement and they will find it very difficult for movements against gravity in terms of uh reflexes, they are going to have hyporeflexia. So again, when you are doing reflexes, you will notice that there will be a very small movement or if not, sometimes you won't see no movement at all. Now again, as a medical student or as a foundation year doctor, when you are doing this, sometimes it could well mean that you have not uh basically striking in the in the right places. So again, do it a couple of times or do it on one side first where you notice where there is movement and on the opposite side, if you notice there are not movements, then you can document that down as hyporeflexia. If in the case that you cannot uh correctly uh elect any reflexes, you can write down that there was no reflexes present or you couldn't actually elect a reflex on that limb. So it's not always good to write down that you've noticed hyporeflexia when in fact, it could have been an error from ourselves in terms of muscle tone. One thing that you do notice, uh which is very, very significant is hypotonic. Again. When you are rolling over the elbow joint or the knee joint, you will notice it's very easy to move over. Sometimes it's so easy that the patient's whole limb will move as well. So that will be very significant in terms of lower motor neurons, you will lower motor neuron lesions. You will also notice that there is a lot of muscular muscle wasting and this is generally due to the motor components of the muscles being affected a lot and the hypotonia and hyperreflexia. So basically, our nervous system isn't able to stimulate a response upon movement and fasciculations are also present in this case. So you will notice very fine movements that are going to be present. Again, this is very common when you, in case of the upper limb, when you do the wrist flexion and extension, you will notice fine movement that are present there. And again, you will notice the same upon ankle dorsi flexion, you will notice a lot of movement within their feet. That is, that is very classical of fasciculations that are being present there in terms of voluntary movements. Yes, they do struggle, they are lost throughout the body. And overall it affects a small area. Let's talk about um Parkinson's in specific for your Aussies. Now, um I believe that they have put a picture up for you. Let's get to that. Why can't I see? Oh yeah, there it is. It's by ra so, so when we are talking about Parkinson's disease, now, Parkinson's disease is a clinical syndrome characterized by bradykinesis, rigidity, tremor and postural instability. Now, a lot of people think that uh Parkinson's disease, it's obviously it's a degenerative disease that patients do have. But the most important thing to diagnosing Parkinson's disease is by taking a very good history and examination that will give you the best diagnosis for Parkinson's disease. Obviously, after that, you can complete getting any scans done, etc. But the most of the time with a good history and examination, you will notice it straight away. So if you see a patient walking into the room just by doing basic examinations and looking at them, so first and foremost, you will be looking at their gait and their walking. So you would get them. First of all, let's say you tell them first thing you want to do is get them to walk through the door. You want to notice if there is any slow shuffling gait that is present there, that is very characteristic of Parkinson's disease. Uh So what they will notice as they are dragging their leg along sometimes midway during the movement or midway during the walk, they may stop. Another thing you may get them to do is rotate to open the door. Now, this can be very difficult for the patient to do. It may take them a time and they may even freeze. This is very characteristic and this is characteristic by knowing that they have a slow shuffling gait. Another thing that you will notice on patients that have Parkinson's disease is they have reduced facial expressions. Now, generally speaking, they will be, when you are looking at them, you will notice that they may be monotonous in their speech also, or they may be hypophonic or very quiet speaking. And also they may tell you that over the past six months or so, they have noticed that their sense of smell has decreased. Now, as we discussed rigidity beforehand. In, in a patient, a classical symptom of a patient with Parkinson's disease is cogwheel rigidity. Now, the best way to do this is passively roll the patient's wrist joint and then noticing if there's any issues with that. So again, like I said, this may take a while, so don't rush this examination, it may take up to a minute to notice this. But when you are rolling the patient's wrist joint at certain points, you may notice almost a resistance against it. So you may have to put a bit more pressure into there. At that point, you can stop the examination and you can down that you've noticed that there is cog cog rigidity again, like like I mentioned before, you can differentiate this from increased uh tone or rigidity because increased tone will be present throughout. Whereas coal rigidity will be present at a specific point during the movement. Now, in Parkinson's disease, when you are checking the upper limb, specifically, the elbow extension has a greater resistance than it does against extension. So when you tell the patient to or when you try to extend the patient's elbow, you will notice at a certain point, it may feel like it's stuck and then gradually it will get better. You will notice this is a lot greater than upon extension. And in case of the lower limb, the knee flexion has a greater resistance than extension. Another thing that you can consider discussing with the patient is asking them about their dexterity. So a common sign that you see for patients with Parkinson's disease is almost like they are rolling their fingers in rolling, rolling their fingers within their hands. So almost like rolling a pill and that's very, very common again. So you will know these are the things that you will notice when you see the patient initially and when you're taking a history and doing your basic uh your doing your examination. Another thing that you can get the patient to do is write down their, let's say, check their handwriting. Now, generally speaking, when a patient or a classical sign that you see with patients with Parkinson's diseases, they have very slow writing movements and also they very small, almost spidery type movements. Again, you can get them to do this on a piece of paper and then you can write down that their handwriting is also effective. So generally speaking, if you get, if you see that four or five of these four or five of these signs are present, you can consider a diagnosis of Parkinson's disease. And then you can also send them in for further scans to confirm the diagnosis. The last thing you want to be doing is something known as the writing reflex. And generally speaking, what? Well, let me explain the writing reflex first. So the writing reflex is basically when you, well, when you actually, before you actually do this uh test for the patient, you would want to explain the test to the patient. So you'll tell the patient. Um hi, I'm a medical student or I'm a doctor and I'm just going to be doing a few tests on you. The test will include you're going to basically stand behind the patient and you're going to tell you're basically going to tug their shoulders. Now, generally speaking, when you tug their shoulders, you're going to tell them they're going to take a couple of steps back to regain stability. In the case of a patient with Parkinson's disease, you will notice that this is a lot longer. So they may need to take four or five steps more to take, uh, to regain their balance. Of course, you should let the patient know that there's no risk that you're not, they're not going to fall over. You're going to stand behind them and you're not going to be pulling too hard upon that. You basically stand behind the patient. Give them a bit of a tug from their shoulders and see how many steps it generally takes for them to regain their balance. Again, if it's taking a lot more than two or three steps, it should be documented again, that gives us a good indication as to it being Parkinson's disease. That's all I have for you today, but I'll pass it on to who's here. So, uh uh Miss Tajani now and then she will continue with the rest of it and then I will answer questions at the end. Perfect. Thank you so much, Doctor Meal. Um So thank you guys for joining. I know we're running over time, so we'll try and round up in the next five minutes or so. Um So essentially we know that the point of this is to prepare us for ays and to basically know how to do a focused neuro exam, but it was important to kind of just know the basics and know what it is you should be tested for as a general rule. So that when you do come to the focused aspect of things, then you know what to do. Um and so mo so essentially moving on. So I think my personal advice for this is that know the conditions like kind of brainstorm, what conditions could come up. Parkinson's is a very easy condition to test. Um multiple sclerosis is a, is another um option that could come up in the Oscar certainly has come up before another one. you know, just bring, there's like lots of things I can't possibly, you know, guess everything that will come up, but there are certain conditions that are so common and it's, you're, you're not gonna get an acute patient. So you're not going to get a patient that's having a stroke there. And then because obviously they need to be in hospital. And for um for us, we were told that we could have real patients whereas in previous years, obviously due to COVID and other things, other factors, um some people have videos that they played instead. And so, you know, I wouldn't rule anything out. I think I would have a general understanding of pretty much any condition that could come up, but focus on the fact that if the briefing for you for this year has said that you're going to have an a real patient, then obviously, it's highly unlikely that assess conditions would come up. And so my advice would be for every condition, brainstorm, the actual symptoms, what are the presentations that you find in these patients? So, moving on to multiple sclerosis, we can see on the screen, there are different things you can test on multiple sclerosis. So for this, you can be given an upper limb exam to do, you could be given a lower limb exam to do or you could be given a cranial nerve exam to do. And so essentially, it's important to note that they won't tell you, oh, test this patient for multiple sclerosis. The point of the neuro exam is to figure out what is it that the patient has. And so at some point, they might give you an indication. So for example, if they're expecting you to have performed the cerebellar exam and you're performing a cranial nerve exam, then the the examiner might guide you to the fact that you should perform a different examination at some point or might tell you the diagnosis whilst you're performing the examination to kind of steer you in a different direction if you're going completely off tangent. So they're not going to leave you to, you know, perform a completely wrong exam because they're trying to test your ability to decipher what this patient has. So as I say, for example, multiple sclerosis, we have a picture here. This is a condition that can affect different parts of the nervous system. So in terms of, you know, as I say, you might be testing the vision because they might commonly present with optic neuritis. And so, whilst they might not necessarily have optic neuritis at that point, they might have other visual deficits. So a common thing that um is associated with multiple sclerosis is internuclear ophthalmoplegia, which is the picture on the right. So I guess understanding your basics because if you understand what internuclear ophthalmoplegia looks like, then you actually know what you're testing. And so therefore, even if you only test the vision and even if you forgot every other thing about multiple sclerosis, but you were able to elicit internuclear ophthalmoplegia in a patient, then you can think, oh wait, actually, you recognize that sign and then that can guide you to test other elements that enable you to know what that condition is. And so um because of time, we won't go into too much detail. The ideal um format of this was to get um people to ideally practice a scenario, but we will try and put more content out there because we know that this is something that people um can struggle with or are worried about and there are conditions that do have an overlap. So you know, if it is something that you could perform more than one examination for, they are nice and they might guide you to perform, you know, an upper limb examination or so, for, for example, if there's something that could present with gait, disturb or weakness, something generic that you could either perform a cerebellar exam for low or lower limb exam for. They might tell you, ok, perform a lower limb exam on this patient. And in which case, you know, you're not confused as to which of the two exams because, oh, actually this symptom fits into more than one examination. Um And so, but it's just good to have that um kind of understanding. And one thing that I found useful when I was thinking about um the the neuro stations was going over some paces um um paces videos. So I know um paces are is a post graduate exam. And so some of the questions they ask at the end can seem a bit more advanced than what you need to know at this moment. But I'm gonna put the links for those pas videos in this chat just so you have an idea of what to expect and how to think about, you know, what to expect because I think a lot of people focus on the examination and don't realize that they might ask you certain questions at the end as well. So, you know, you will be asked to present your findings and then you might be asked, you know, how would you manage this patient and you could be asked different questions relating to the um presentation that the patient has come in with. So, you know, you need to know your investigations, your management, um and things like that. So essentially I'm gonna post three links in the chart just now. So if you just bear with me and then you guys could um, just watch those videos and we'll try and get you some more information that can help but just bear with me while I while I sort that out. But in the meantime, if you do fill in the feedback, I will go on to the feedback slide. Um Our next session is next week Monday and that will be run by Doctor Lisa Quinn, which a lot of us are familiar with. So it would be great to see you guys there. Um But yeah, if you fill in the feedback, I'll send the links to the pas videos because I think they are very, very useful. Um And so therefore would guide you to, to kind of understand what it means in performing a focused neuro exam rather than just the generic one. So I'll place those in the chat now in the meantime, scan the link for the QR code and that would be very helpful. Thank you. So, I've just posted one of those links. I will send about three videos because they were all very specific. So to kind of give you an idea of what kind of things? So one was a visual exam. So cranial nerves and one was the lower limb and the other was an upper limb. And so it's just to get you thinking about not just the examination, but also the kind of questions that might come up after the examination because I think that's what some people um usually find a bit more difficult because they don't expect the questions afterwards as well because they might ask you anything related to that condition. So, so that's why I say always start with a conditions list all the findings and how you would manage or treat those. So I've just sent three M RCP patients. As I say, this is a postgraduate exam. So if you hear some things that think, oh how was I supposed to know that you might not need to know that at this level, but it's just a very good way to kind of get you in to understand the structure of a focused neurological examination rather than just doing the whole thing. Um And we will try and get some more information out as well to help with the Aussies later. Um I think someone's just put a question in the chat. So you're not necessarily told what examination to find out uh to perform Joshua. So they might just tell you this patient has presented with a tremor, examine them. And so in that sense scenario, the most likely thing that you'll be performing is a Parkinson's focused examination. And then, but for some presentations, it might be, it might overlap. So as I say, a cerebellar examination might overlap with a lower limb examination. So in which case, if they give you a, a presenting complaint that might lead you to two different examination findings, they might tell you, ok, then, you know, perform a lower limb rather than a cerebellar. So they wouldn't say rather than a cerebellar, but they will just tell you what to do if it is something that can be ambiguous. But most times the whole point of it is for you to figure out what you're meant to do. So, if someone comes in with a visual disturbance, you're not gonna do an upper limb examination on them. Does that make sense? Yeah, perfect. If there's any more questions, then please let us know um we'll hang around for just a few more minutes. Um.